24th February 2025

Management of OA

The effective management of OA requires a coordinated, holistic, multidisciplinary approach, aiming to minimise symptoms and maximise function. Unless there is a secondary cause, there are no pharmacological therapies that can halt or reverse the disease process. The impact of OA cannot be overstated in terms of poor quality of life and mental health, namely the deleterious effect on the ability to work, enjoy leisure activities, self-care and sleep. Important aspects of care include:

• Functional assessment by both physiotherapists and occupational therapists for joint supports, walking aids and adaptations to the home environment. Exercises can be taught to optimise joint function and reverse muscle wasting, helping with mobility and, importantly, overall cardiovascular health.
• Weight loss should be encouraged, particularly if central, weight-bearing joints are primarily affected, as ongoing mechanical stress will cause progressive joint damage.
• Analgesia should be titrated in a stepwise manner, taking into account the distribution of joints affected, patient comorbidities and potential drug reactions, as comorbidity is common. The management of patient expectations regarding pain relief is an important consideration of chronic pain management.
  • Step 1: Regular Paracetamol 1 g, four times a day, with a topical NSAID gel such as diclofenac (particularly for hand and knee disease).
  • Step 2: Switch topical for oral NSAIDs such as ibuprofen, if not contraindicated (either relatively due to age or absolutely due to cardiovascular, gastrointestinal or renal disease). The risk may be reduced by co-administering a proton pump inhibitor. Alternatively, for disease predominantly affecting a specific joint, intra-articular corticosteroid injections may be beneficial (up to 3-4 injections per year). There is no evidence for oral or injected viscosupplements.
  • Step 3: In refractory cases or where previous therapies are contraindicated, weak opiates such as codeine may be used, with or without neuropathic agents such as gabapentin or pregabalin.
  • Step 4: NICE does not recommend strong opiates such as morphine for refractory pain, otherwise difficult to manage; therefore, the next step is referral to Orthopaedics for the consideration of a joint replacement, especially if there is a significantly reduced quality of life.